You Make the Call: Risk or Opiophobia?

You Make the Call: Risk or Opiophobia?

bigstock-Surgeons-See-more-in-my-portf-12370376Kurt W.G. Matthies is former computer engineer and freelance writer who has lived with the chronic intractable pain of severe spine disease for over 20 years. As a former Contributing Editor to MacUser and columnist for other trade journals, Kurt now writes about chronic pain for the National Pain Report. You can follow Kurt @kwgmatthies on Twitter.

As a writer and advocate with an intensely personal interest in the treatment of chronic pain, I try to stay current with available medical research related to our understanding of chronic pain and its treatment. In this time of great suffering in the chronic pain community, I take a special interest in medical research involving pain medication.

Let me back off for a moment. My training is in engineering. I’m not a doctor. Understandably, many wonder how I can read these esoteric scientific documents, or where I get my medical knowledge. So, allow me a moment to share some of my personal history.

When I was a teen many years ago, I took a terrible fall trying to learn “technical” mountain climbing. I was hospitalized for over two months, underwent the same surgery four times, and almost lost my life in that hospital due to an undiagnosed medical condition. The good news is that after a successful hematology grand round episode and some treatment with fresh-frozen plasma, I’m here to write the anecdote today.

It was in that hospital that I began to read medical textbooks. The practice became a habit that I developed in self-defense. I have a rare blood condition and I’ve had to educate most physicians about it throughout my life. For instance, because of my blood disease, I can’t take NSAIDs or I’ll develop an internal bleed.  My chronic pain results from a severe case of spinal osteoarthritis (spondylosis), and what’s the first treatment most doctors think about when you’ve got arthritis – NSAIDs.

Through the years I’ve read my way through A&P, histology, hematology, neurology, and other fields, but for many years now I have focused entirely on subjects related to pain medicine. Reading medical lingo has become almost second nature.

Granted, reading medical literature is a strange hobby, but it’s mine.

Recently, I discovered the report of a medical study relevant to the special needs of people like me. This report was presented at the American Society of Anesthesiologists 2014 annual meeting and it examined the electronic medical records of VA patients who had inpatient surgery in 2011, excluding those whose diagnosis included cancer.

It seems doctors like to separate people in pain into two categories – those who have the pain of terminal cancer, and those of us who hurt real badly but aren’t yet terminal.

Please bear with me as I report a few technical details of this research.

The size of the sample group of this study, (usually called ‘n’ and an important factor in deciding the relevancy of any statistical study), included over sixty-four thousand subjects; primarily men between the ages of 55 and 65 years, white (80%), and that had significant comorbidities – a description that fits me to a T.

These 64,000+ subjects were stratified by the extent of their opioid regimen (if any) prior to surgery, as:

Treatment Prior to Surgery Length of Treatment (d) Patient Population (%)
opioid-naïve None 46%
tramadol only More than 90 days 8%
short-acting opioid Less than 90 days 24%
Short-acting opioid (COT) More than 90 days 17%
Long acting opioid (COT) More than 90 days 5%

 

After surgery, these patients were treated with opioids to control pain. In this study, researchers were interested primarily in measuring the number of days opioid analgesia was required after surgery. These findings are reported as follows:

Treatment Prior to Surgery Opioid Analgesia Required Post Surgery (in days)
opioid-naïve 15
tramadol only 132
short-acting opioid (< 90 d) 53
Short-acting opioid (COT) 365 or more
Long acting opioid (COT) 365 or more

 

Study lead author, Seshadri C. Mudumbai, MD, a physician at the VA Palo Alto Health Care System commented on the results: “We found that opioid-naive patients would come off opioids quickly, but patients already on short-acting chronic opioids and long-acting opioids were basically on opioid regimens for the full year postoperatively or longer.”

He continued: “When we accounted for all factors, preoperative opioid burden was the strongest predictor for postoperative opioid use,” said Dr. Mudumbai. “Patients with short-acting chronic use and long-acting opioids were about nine times more at risk [italics mine] for prolonged opioid use versus patients who were opioid-naive before surgery.”

Wow. At risk?

These docs looked at a large population of patients who had surgery, some of whom needed chronic opioid therapy (COT) prior to surgery.  They studied the length of time these people needed opioids after surgery and used it as a predictor of opioid needs in the COT group.

Sometimes people have surgery to treat a painful condition. I could expect a certain percentage in that sample group to stop using opioids after surgery.

But this study says nothing of the kind of surgery these patients underwent. Perhaps some of these were surgeries to reduce pain, but I would imagine that a great percentage of the 64,000 underwent a wide variety of surgeries, the kind of which is performed in VA hospitals all over the country.

So why in the world would you consider data regarding length of post-op opioid treatment in the two groups of patients that required COT prior to the study? People who require COT have chronic pain.

Dr. Mudumbai remarked that people with a history of prior chronic opioid use are “at risk” for prolonged opioid us post-surgery.

I ask – where’s the risk? They needed COT before their pain was exacerbated by surgery.

He continues with the statement that the COT group was “nine-times more at risk for prolonged opioid use.”

Nine-times more likely, Dr. Mudumbai? I’d say that these two groups formerly on COT were 100% more likely to require opioids during the entire year-long study period.

Their need for opioids had little to do with surgery or prior opioid use.

THEY NEEDED OPIATES BEFORE AND AFTER THEY UNDERWENT SURGERY BECAUSE THEY LIVED WITH CHRONIC PAIN!!!

Yes, the risk for needing opioids in the population that lives with chronic pain is high. For us, this is not a risk, but an essential medical treatment that allows us to live a productive life.

The word “risk” carries certain negative connotations.

Are hypertensives at risk for needing vasopressors? Are Type 2 diabetics, or people with COPD, coronary artery disease, or asthmatics at risk for requiring medication?

That’s one way of thinking about it.

But isn’t the medical treatment of disease an inevitable conclusion? Mr. Walgreens sure would have had to find another job if it weren’t. Where’s the risk?

How many of us are at risk of receiving a prescription for medication when we visit our doctor?

Was this yet another opioid-bashing report, exposing the researcher’s opioid bias?

There’s a name for an opioid bias. It’s called Opiophobia.

Risk or Opiophobia? What do you think?

Information from Clinical Pain Medicine, March 2015, Volume 13 was used in the preparation of this article.

 

Authored by: Kurt W.G. Matthies

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Jennifer

The issue calls for a war on the war on drugs. Does anyone no how to begin fighting Opiophobia? I’ve never been an active activist for any cause but I’ll do whatever I can fight the discrimination I face every month trying to find a pharmacy to fill my scripts on time and every time I see a doctor for any reason. How do we address this effectively without looking like political Junkies?

Mary

Thanks Great Article,
I would love if we (Chronic pain peeps) could have a voice weather be on TV or Newspapers. Get these docs that toss out opinoins calling them stats. I’ll bet not one could walk a day in our shoes (if on good day we can walk or even put shoes on) or follow us few days see how much fun we have day to day. Makes me sick and depressed to have to take meds just to walk, not drive, not have my social job (I loved) not go to my childrens functions (due to no place to sit for me) Have loss of friends. This is a very lonely thing we live with. And to find a doc that gets it is rare, hard and takes many of years. So I would challenge any of these doctors/ pencil pushers of stats to come join me for fun filled day of pain.
Thanks for great info and great article
Mary

cassy

I dont understand why we cannot start a class action suit. I am involved with several chronic pain sites and hearing sufferers stories makes one thing clear: the chronic pain patient is the most discriminated group in the US and abroad.

I would just like to remind folks that opioids are probably safer for the body than uncontrolled constant pain. Though doctors never tell us this, pain does considerable damage to the nervous and hormonal system.

You can find this documented on WebMD:
http://www.webmd.com/pain-management/features/prescription-painkiller-addiction-7-myths

and also EDSinfo:
https://edsinfo.wordpress.com/opioidsnarcotics/pain-opiates-perceptions-vs-reality/

Brenda Alice

The patients with chronic painful diseases need help immediately. I have been on narcotics for over 15 years. I am not proud of this but narcotics have allowed me to have a limited life even though the pain never stops. Narcotics make my life manageable. I have post laminectomy syndrome,peripheral neuropathy,interstitial cystitis,sciatica,dysautonomia, chronic gastritis and am missing my gall bladder, 30% of colon from adhesions, a complete hysterectomy and should be a easy patient. Unfortunately the chronic pain has destroyed my life and family. I have lost 2 wonderful careers. With the narcotics I am able to walk and sit for brief periods. The DEA interference has caused my medication to be cut 1/3 taking away the ball games for the grand children I use to be able to tolerate. Allow patients to make the choice of suffering needlessly or having a better life with necessary narcotics. I have tried alternatives without success. Limiting the primary care physicians of prescription abilities already force the shortage of pain management. Please watch Ken Mckin on utube about the loss of compassion. The DEA interference and targets on pain specialists is ridiculous when they should be after the criminals. I have 4 chronic conditions that cause pain that have no cure except death.

Kathy

This type of “research” being repeated in other fields as well. I have seen recent medical scholarly articles examining opioid use before and after orthopedic surgeries involving the hip or shoulder. Guess what, patients who use narcotics before surgery are at risk for using narcotics after surgery. Is there any mention of WHY they use narcotics before surgery? Perhaps they have had several failed surgeries and are undergoing some type of salvage procedure that has no possible hope of reducing pain, but may allow more function?
I have read where a surgeon announces he or she will not help a patient who takes narcotics. They do not explain their reasoning.

When I hear providers throw out numbers like this
one; 50% of Americans are treated for chronic pain !

Where does this information come from ?
After 25 years of personal experience I can say
that the number is much less or more like 5% that
are actually receiving medication.

Maybe it’s because Pain is now a Big Business with
all forms of providers looking to cash in. Chiropractors and
Hypnotist and even non licensed quacks that push any devise
that will produce heat or vibration. Get a patch cuz it works for
Shaq.

The day the government makes alcohol illegal again maybe
I will be convinced they really do care but that will never happen.
Cigarettes cause more health problems but the tax money is in the
billions of dollars.

People with real chronic pain are the losers here and relaxation
therapy is not the answer, Dogs get better treatment because Americans
can’t bare to watch the poor thing suffer.

This is one messed up country and now it’s
heartless.

Thank you,

jjs

Jean Sutherland

It just drives me insane when studies like this seem to blame chronic pain patients for their pain. You are dead on…if we needed it for pain before surgery, we’re going to need it afterwards. Having a gall bladder operation is not going to relieve my chronic sacrum pain that I’ve had for 11 years. Thanks for your article.

I would say this report is biased against opioids. I would think it would be apparent that people using opioids for chronic pain would continue to be on them after surgery.

Kurt, your story sounds so much like mine!

I worked in high tech as well until my increasing invisible and undiagnosed pain interfered too much and I had to stop in 2008. It took 4 more years before I was finally diagnosed with the connective tissue disorder, Ehlers-Danlos Syndrome, and it was solely the result of my own persistent research. Studying and learning is a constant in the quickly changing tech field, and that habit is certainly serving us well now!

I, too, turned my remaining skill and energy into advocating for pain patients through research and writing. I started doing the research for myself, but then decided to blog it so it would be an accessible resource for others in my situation. I’ve created a curated collection of annotated articles (some from this very National Pain Report) on EDS, Fibromyalgia and chronic pain (including the opiate crisis), plus a few writings of my own.

I want to advocate more actively, but have little energy to spare, so please let me know if you have any ideas about how I could be helpful.

The wording of pain research articles is also one of my pet peeves, and I’m glad you’re pointing it out. Another couple of my favorites:

– Higher opiate doses associated with greater depression
should be: Higher opiate doses associated with greater chronic pain, which causes depression

It’s a matter of word order: “Greater depression associated with higher opiate doses” sounds completely different and has different implication than the original title

– High rate of opioid use among SSDI recipients
should be: High number of SSDI recipients disabled by chronic pain and receiving COT

Someday, today’s opiophobic media hype will seem just as ignorant, mean-spirited, and downright silly as the “reefer madness” propaganda of the last century.

Mark Ibsen

Those of us who are dog mushers are at risk to step I dog shit.
In my experience, it is also 100%

Anonymous

Great Article!

A cognitive dissonance occurs when you try to apply Engineering and Science, to Medical “Science”. In Medicine the rule of Empirical Science do not apply! Skewed Data., Old Wives tales, and Prejudices do!

Jon Morgan-Parker

Sir ,
I have been using opioids in patch form for some years now. I am concerned for my health risks not to mention my life expectancy reduction! Trying to quit them is not an option for me because surgery is not an option either , as my back is in such a mess.
I am also using Tramadol 4 times a day , which is also a worry and I fear for my kidneys too.
I am going to speak to my doctor in the next few days about my concerns and I have also tried to lower my dose in the past , but it was extremely difficult and traumatising .

TOPDOG

The D.E.A. and F.D.A. have become the U.S. equivalent of Gestapo S.S.. The D.E.A. was a bad idea to start with and has only gotten worse ever sense. States are able to do their job. They don’t need the D.E.A. I don’t need the D.E.A. You don’t need the D.E.A. .Nobody needs the D.E.A. They are misappropriating and commandeering billions of dollars of public funds that America can no longer justify..Their funding needs to be cut by,at least, ninety-five percent and all need to be restructured to a much smaller and much more restrained gang of Authoritarian sociopaths.. This is a group of renegade law enforcement completely out-of-control .and way over-the-top.They are using the war on drugs as a smokescreen and a ruse to subvert our Civil and Human rights and increasingly more as a ruse to seize cash and property in their war on the American people.Also, through gross incompetence, have made it nearly impossible for a pain sufferer to get treatment without being thrown in jail

paita

Sorry CP@ohchr.org,,,not cp@ohchr.org,,,sorry,,,paita

Terri Lewis PhD

This is exactly like saying that persons who relied on insulin delivered by any method for 365 days prior to surgery, were ‘at risk’ for reliance on insulin after surgery for 356 days or more.
One would assume that a surgical intervention for a consumer who has had chronic pain for 365 days or more, is unlike to see a surgical procedure of any kind eliminate their chronic or centralized pain because they are unrelated. Surgery might improve a physical issue, but centralized pain is not going to be eliminated by a surgical process. This illustrates how poorly theorized pain is by the medical profession.

paita

See,,this is the kinda crap studies the D.E.A. uses to justify killing chronic pain people,,,all there so -called data was from Doctors paid by our tax dollars,,government employees,,,dahhh,,,of course there gonna side w/the D.E.A.,,its time we fight back guys,,,big time,,,email the U.N..Human Rights Council at cp@ohchr.org,,,,,and add your name to the list of those filing a formal complaint against the D.E.A.,,,,paita